On chest imaging, mesothelioma usually presents as a unilateral pleural effusion in 30 to 95% of cases,3,4 often with mediastinal shift toward the affected side. The involved pleura is characteristically thickened, lobulated, or nodular on chest CT imaging.3,4 Because advanced mesothelioma tends to be locally invasive, chest imaging may show chest wall invasion and rib destruction, or direct extension into the mediastinum.3,4 Regional invasion may also produce enlargement of ipsilateral hilar and mediastinal lymph nodes. Mesothelioma can metastasize hematogenously to distant sites, including the contralateral lung, but this pattern is rarely detected premortem. Interestingly, hematogenous metastases are more common than lymphatic nodal spread, and have been noted in 70 to 83% of patients at autopsy, with most common sites being liver, peritoneum, intestines, adrenal glands, brain, and bone.3,5–7 Metastatic pulmonary nodules have been reported at autopsy, but in these cases were not evident radiographically.6,8 Hematogenous metastases were equally common in all cell types (epithelial, sarcomatous, and mixed) of mesothelioma in one autopsy study of 42 cases.5 When hematogenous spread of mesothelioma is detected radiographically, pulmonary masses are usually accompanied by pleural effusion (> 85% of cases), and when seen are more typically focal masses or pleural-based lesions. In our patient, a small, loculated left lower pleural effusion was evident. However, we do not suspect this as the initial site of disease before dissemination, because the pleural surfaces were smooth and well defined, and the effusion remained small and stable over serial imaging studies.